Design principles for clinical reasoning

Clinical reasoning is hard to do, and even harder to facilitate in novice practitioners who lack the experience and patterns of thinking that enable them to establish conceptual relationships that are often non-trivial. Experienced clinicians have developed, over many years and many patients, a set of thinking patterns that influence the clinical decisions they make, and which they are often unaware of. The development of tacit knowledge and its application in the clinical context is largely done unconsciously, which is why experienced clinicians often feel like they “just know” what to do.

Developing clinical reasoning is included as part of clinical education, yet it is usually implicit. Students are expected to “do” clinical reasoning, yet we find it difficult to explain just what we mean by that. How do you model a way of thinking?

One of the starting points is to ask what we mean when we talk about clinical education. Traditionally, clinical education describes the teaching and learning experiences that happen in a clinical context, maybe a hospital, outpatient or clinic setting. However, if we redefine “clinical education” to mean activities that stimulate the patterns of thinking needed to think and behave in the real world, then “clinical education” is something that can happen anywhere, at any time.

My PhD was about exploring the possibilities for change that are made available through the integration of technology into clinical education. The main outcome of the project was the development of a set of draft design principles that emerged through a series of research projects that included students, clinicians and clinical educators. These principles can be used to design online and physical learning spaces that create opportunities for students to develop critical thinking as part of clinical reasoning. Each top-level principle is associated with a number of “facets” that further describe the application of the principles.

Here are the draft design principles (note that the supporting evidence and additional discussion are not included here):

1. Facilitate interaction through enhanced communication

• Interaction can be between people and content
• Communication is iterative and aims to improve understanding through structured dialogue that is conducted over time
• Digital content is not inert, and can transform interactions by responding and changing over time
• Content is a framework around which a process of interaction can take place – it is a means to an end, not an end in itself
• When content is distributed over networks, the “learning environment” becomes all possible spaces where learning can happen
• Interaction is possible in a range of contexts, and not exclusively during scheduled times

2. Require articulation

• Articulation gives form and substance to abstract ideas, thereby exposing understanding
• Articulation is about committing to a statement based on personal experience, that is supported by evidence
• Articulation is public, making students accountable for what they believe
• Articulation allows students’ thinking to be challenged or reinforced
• Incomplete understanding is not a point of failure, but a normal part of moving towards understanding

3. Build relationships

• Knowledge can be developed through the interaction between people, content and objects, through networks
• Relationships can be built around collaborative activity where the responsibility for learning is shared
• Facilitators are part of the process, and students are partners in teaching and learning
• Facilitators are not gatekeepers – they are locksmiths
• Create a safe space where “not knowing” is as important as “knowing”
• Teaching and learning is a dynamic, symbiotic relationship between people
• Building relationships takes into account both personal and professional development
• Building relationships means balancing out power so that students also have a say in when and how learning happens

4. Embrace complexity

• Develop learning spaces that are more, not less, complex
• Change variables within the learning space, to replicate the dynamic context of the real world
• Create problems that have poorly defined boundaries and which defy simple solutions

5. Encourage creativity

• Students must identify gaps in their own understanding, and engage in a process of knowledge creation to fill those gaps
• These products of learning are created through an iterative activity that includes interaction through discussion and feedback
• Learning materials created should be shared with others throughout the process, to enable interaction around both process and product
• Processes of content development should be structured according to the ability of the students

6. Stimulate reflection

• Learning activities should have reflection built in
• Completing the reflection should have a real consequence for the student
• Reflection should be modelled for students
• Reflections should be shared with others
• Feedback on reflections should be provided as soon after the experience as possible
• Students need to determine the value of reflection for themselves, it cannot be told to them

7. Acknowledge emotion

• Create a safe, non­judgemental space for students to share their personal experiences and thoughts, as well as their emotional responses to those experiences
• Facilitators should validate students’ emotional responses
• These shared experiences can inform valuable teaching moments
• Facilitators are encouraged to share personal values and their own emotional responses to clinical encounters, normalising and scaffolding the process
• Sensitive topics should be covered in face­to­face sessions
• Facilitators’ emotional responses to teaching and learning should be acknowledged, as well their emotional responses to the clinical context

8. Flexibility

• The learning environment should be flexible enough to adapt to the changing needs of students, but structured enough to scaffold their progress
• The components of the curriculum (i.e. the teaching strategies, assessment tasks and content) should be flexible and should change when necessary
• Facilitators should be flexible, changing schedules and approaches to better serve students’ learning

9. Immersion

• Tasks and activities should be “cognitively real”, enabling students to immerse themselves to the extent that they think and behave as they would be expected to in the real world
• Tasks and activities should use the “tools” of the profession to expose students to the culture of the profession
• Technology should be transparent, adding to, and not distracting from the immersive experience

We have implemented these draft design principles as part of a blended module that made significant use of technology to fundamentally change teaching and learning practices in our physiotherapy department. We’re currently seeing very positive changes in students’ learning behaviours, and clinical reasoning while on placements, although the real benefits of this approach will only really emerge in the next year or so. I will continue to update these principles as I continue my research.

Note: The thesis is still under examination, and these design principles are still very much in draft. They have not been tested in any context other than in our department and will be undergoing refinement as I continue doing postdoctoral work in this area.